Objective: The study was conducted to find out the history of
childhood abuse and neglect in addicts and non addicts, and to examine
the difference between childhood abuse and neglect in both groups. It
was hypothesized (a) childhood neglect and abuse is reported more in
addicts than non addicts. (b) There is a difference between the
prevalence of the type of childhood neglect and abuse in these groups.

Research Design: Matched group design Place and Duration of Study:
Lahore, Pakistan. January to September 2009.

Sample and Method: Sample of 50 addicts and 50 non-addicts were
collected in Lahore, Pakistan. The research followed the (American
Psychiatric Association [DSM-IV-TR] diagnostic criteria for drug
addiction/substance dependence. A demographic questionnaire and
childhood trauma questionnaire were used.

Conclusion: The study provides evidence that addicts were more
likely to have experienced childhood abuse and neglect than to non-
addicts. This population might benefit from the support of government,
and different health professionals.

Key Words: Addicts; non-addict; childhood neglect and abuse

INTRODUCTION

Substance dependence or addiction is a widespread and strongly
rooted problem of the Pakistani society. People frequently (irrespective
of age and gender) become the victims of Substance dependence or drug
addiction. Substance dependence is manifested by three (or more) of the
following symptoms: tolerance, withdrawal, prolonged use of substance in
larger amount, unsuccessful efforts to cut down or control substance
use, engaging in activities to obtain substance, repeated physical or
psychological problems and social and occupational impairments1. The
most common types of substance that cause dependence are depressants,
stimulants and hallucinogens.

Existing empirical evidences indicated that environmental factors
(such as unemployment, insufficient recreational facilities, peer
pressure, and parenting styles) contribute to making a person prone to
drug addiction. However another serious environmental factor is
childhood neglect and abuse. While physical abuse, emotional abuse,
sexual abuse, emotional neglect and physical neglect might be
independent; they are also frequently occurred in combination. The most
common types of substance that cause dependence are depressants,
stimulants and hallucinogens.

There are different types of childhood abuse and neglect which are
as follows:

(a) Physical abuse refers to non-accidental physical injury that
ranges from minor bruises to severe fractures. It is caused by a parent,
caregiver/caretaker of the child. Such injury is considered abuse
regardless of whether the caregiver intended to physically hurt the
child.

(b) Sexual abuse includes activities such as touching a
child's genitals, penetration, incest, rape, sodomy, indecent
exposure, and exploitation through prostitution or the production of
pornographic materials by a parent, caregiver or adult.

(c) Emotional abuse or psychological abuse also harms a
child's emotional development and sense of self-worth. This
includes constant criticism, threats, or rejection, as well as
withholding love, support, or guidance.

However, Baldwin explained that Neglect is the failure of a parent,
guardian, or other caregivers to provide for a child's basic needs.
It has two types: physical and emotional neglect. Physical neglect
refers to failure to provide necessary food or shelter, or lack of
appropriate supervision to the child. Emotional neglect is the
inattention to a child's emotional needs, and failure to provide
psychological care.

Those individuals who face childhood trauma (abuse and neglect) are
at a higher risk of developing psychological problems like depression,
anxiety disorders, personality disorders and substance dependence.
According to Spertus, Yethuda, Wong, Halligan, Seremetis several
psychological, social and physical problems are associated with
childhood abuse (such as verbal and physical abuse) and neglect (e.g.,
physical and emotional neglect). Gerra et al found that childhood abuse
and neglect is a serious risk factor for drug addiction or substance
dependence.

History of childhood maltreatment (abuse and neglect) is a serious
factor in risk for addiction. Lundgren, Gerdner and Lundqvist studied
(n=55) Swedish female addicts with mean age of 34.7 years. They
administered Childhood Trauma Questionnaire (CTQ) in Swedish language,
and found that 94.5 Percent females had experienced childhood abuse and
neglect. Among them 35-40 Percent had experienced a severe level of
physical and emotional abuse and neglect.

Formerly, Substance dependence was treated as a genetic problem.
Such as Goodwin found that alcoholism is associated with psychological
problems in families including; depression, sociopathy, criminality and
personality disorders. However, it is difficult to separate
environmental factors from genetics, because these factors played
important role in expression of the genes in the individual. For
example, childhood maltreatment interrupts a normal emotional regulation
and self-concept which may result in the individual developing mental
disorders such as addiction, depression etc. That is why contextual
factors such as negative childhood experiences (childhood abuse and
neglect) get more importance in the developing countries because of
rapid increase of drug addicts.

According to the National Survey on Drug Abuse 1993 there were 3
million drug addicts in Pakistan. According to this report age range of
72 Percent drug addicts was 24 to 30 years and 51 Percent drug addicts
were heroin abusers. However, Anti-Narcotics department reported 6
million addicts in 2010. Although the Draft of the Anti-Narcotics Policy
2010 mentioned that there was no recent statistics were available about
the drug addiction in Pakistan.

Another published survey gave statistics across various occupations
the percentage was labor class 53.3 percent, sales persons 14.1 percent,
agriculture workers 10.9 percent and students 11.4 percent. Rates varied
by age and region. Punjab had the highest rate of addiction, 71 per cent
of addicts fell between 25- 30 years of age. In terms of gender 90
Percent of drug addicts were males and 10 Percent were females. In
Furthermore, heroin was found to be the most commonly used addictive
substance (51 per cent of addicts). The second most popular drug was
hashish, which was used by 29.5 per cent of the addicts. Other addiction
users took charas, opium, alcohol, cocaine, and tranquilizers (e.g.,
Valium, Librium, Ativan, Diazepam).

Likewise, Rostami, Zarei, NejadandLarijani conducted a study of
history of abuse in Iranian addicts and non addicts for studying the
evidence of childhood abuse. Their sample size was 200 (100 addicts and
100 non addicts) and they administered Child Abuse Self Report Survey
(CASRS). The comparison suggested a significant mean difference in
experiencing childhood abuse in two groups (a=0.05 t=3.604).

Furthermore, Conroy, Degenhardt, Mattick and Nelson conducted a
study in Australia to compare childhood maltreatment in opioid dependent
group and non-opioid dependent group. They conducted interviews with
nearly 100 opioid dependents with mean age 36.5, 61 Percent of which
were male, and 346 non -opioid dependents with mean age 34.7 Percent ,
45 Percent of which were male. While childhood neglect and abuse was
present in both groups, it was significantly more prevalent in opioid
dependent groups.

Thus the previous literature suggests that history of childhood
abuse and neglect is a prominent problem in addicts. However such
research has not been done in Pakistan. Research can help clinical
psychologists to better understand the significance of this problem, and
to possibly developing an intervention in this population.

Therefore, the present study was conducted to study(i) the
prevalence of the childhood abuse and neglect, and (ii) to find out a
difference between the type of childhood neglect (emotional and
physical) and abuse(emotional, physical and sexual) in addicts and
non-addicts.

METHOD

The present study used a matched groups design. For matched group
design researcher selected the participant for one group and then
matched them on some relevant characteristics e.g., age, gender,
education and etc. with the other group. This approach controls the
variability in the data set to create more comparable groups with regard
to variables not of central interest in the study under special
circumstances. This is a good alternative when a random groups design or
repeated measures cannot be used.

Sample

The sample was comprised of 100 males consisted of 50 addicts and
50 non addicts. Purposive sampling was used for the collection of the
data. The group of addicts was based in three private rehabilitation
centers in Lahore, and the non addicts group was comprised of members of
the general population of the Lahore. Addict inclusion criteria were age
range of 18- 55, history of substance dependence (according to DSM-IV
TR, 2000)1, and a minimum of 14years of education. The inclusion
criterion for non addicts was no history of drug addiction. The latter
group was matched on the following demographic characteristics: age,
sex, profession and monthly income. Age and income the groups were
matched with the flexibility of (+-3 years) and (+-Rs, 3000)
respectively. The mean ages were 31 and 29 years for addict and
non-addict group respectively, and mean income was Rs, 3892 and Rs,
36660 for addicts and non addicts respectively. Hence it is revealed
that both groups were fairly matched on age and income variables.

Matching on other demographic characteristics is indicated in
following table:

Table 1 Demographic Characteristics of the Sample (N=100)

Demographic Variable###Addicts###Non - Addicts

###f###Percent###f###Percent

Gender

Male###50###50###50###50

Education

B.A/Bsc/B.ed/BBA###46###46###45###45

MA,MSc,MBBS###4###4###5###5

Profession###

Students###15###15###17###17

Businessman###13###13###15###15

Govt. employee###12###12###12###12

Private employee###11###11###12###12

Landlord###04###04###03###03

Type of Drug

Heroine###05###10###-###-

Cannabis###02###04###-###-

Sedatives###02###04###-###-

Alcohol###10###20###-###-

Two-drugs(incombination) 15###30###-###-

Marijuana###10###20###-###-

Opium###03###06###-###-

Three-drugs(in

combination)###03###06###-###-

Measures

Demographic Questionnaire

The researchers developed a demographic data form for participants
with the purpose of collecting matched group participants (non-
addicts). This form includes items regarding: age, gender, education,
occupation, monthly income, history of drug addiction.

A Childhood Trauma Questionnaire (CTQ)

The CTQ2 was used to measure participant's childhood
experience of abuse. The test - retest reliability was 0.88 and range of
internal consistency was 0.80-0.97, and the criterion validity was
assessed and was found acceptable (Bernstein and Fink, 1997)2.

The CTQ2 included five subscales: physical abuse, emotional abuse,
sexual abuse, physical neglect and emotional neglect. The questionnaire
is comprised of 28 items that are rated on a 1-5 point scale (where 1
stands for minimum and 5 for maximum). Each sub scale had a total score
of 25. The total score of the test was obtained by adding the values on
each item. It had also 3 items for detecting Denial (false-negative
trauma reports). Each sub scales scores were transformed into
percentiles according to the CTQ2 manual and the percentile were used to
determine the severity levels of the childhood experience of abuse
(Minimum-Low, Low-Moderate, Moderate-Severe and Severe-Extreme).

Procedure

The researcher gathered data from three rehabilitation centers in
Lahore. Before the data collection, management of the rehabilitation
center was assured that information taken from the patients would be
kept confidential and only used for research purposes. In addition,
written permission was sought from the executive bodies of the
rehabilitation centers for the collection of data. Afterwards, written
informed consent was also taken from each drug addict. Subsequently, the
matched group (non addicts) was taken from the general population of
Lahore city. Similarly, written informed consent was also taken by them.
Moreover, both groups were also provided with a brief description of the
nature and purpose of the research, and were informed that their
identity, and the information collected from them would remain
confidential and would only be used for academic and research purposes.
Data were collected by a single researcher.

All the three tools (Demographic form, DSM-IV-TR , 20001 Criteria
and CTQ2) were in English (as the minimum educational criterion for the
participant to get recruited in the study was 14 years of education),
and administered individually. The total time spent with each
participant was 25-30 minutes.

Statistical Analysis

The data were analyzed using descriptive analysis and independent
sample t-test. In the present research, five independent sample t-test
were run on the scores of the data; therefore, Bonferroni correction for
multiple testing had been used, and it gave a significance level
of[[1-0.95]] ^(1/5)=0.0117.

RESULTS

Table 1 Frequencies and Percentages on Scales on Childhood Abuse
and Neglect for Drug Addicts and Non-Addicts (N=100)

The study was conducted on sample of 100 males (including 50
addicts and 50 non addicts) to explore the role of childhood abuse and
neglect in substance dependence or drug addiction in the population of
Lahore, Pakistan. The present study aims to add to limited existing
Asian research data in this area.

The results of the present study revealed that both groups had
experience of childhood abuse and neglect, but groups differed
significantly in the experience of childhood abuse and neglect. The
results of the present research confirmed the results of the various
previous studies. For instance, Faran, Saeed and Mohammad reported that
95 Percent of their addicted participants reported physical and sexual
abuse in childhood. Similarly, Mitsuru et al conducted the study in
Japan and found the following reporting of childhood maltreatment:
physical abuse (53.7 Percent ), psychological abuse (60.4 Percent ),
sexual abuse (5.4 Percent ) and neglect (24.5 Percent ) and comparison
between drug abused and non-drug abused groups determined that abused
participants more often reported childhood maltreatment. Moreover other
researchers studied the prevalence of childhood neglect and abuse in
males and females in the rural area of South African.

Hence, the prevalence rate of the childhood abuse and neglect of
the present study was in consistent with previous literature. Besides
this, in the present study addicts were more likely to experience severe
childhood abuse and neglect than non-addicts; therefore, intensify form
of childhood abuse and neglect might be the possible reason of their
using addictive drugs in adulthood. Thus the data support Bernstein and
Fink suggestions that adults with history of childhood abuse and neglect
may be at high risk for developing substance abuse disorders.

Likewise, Conroy, et al16 studied opioid dependents and non-opioid
dependents in Sydney and found the groups differed significantly in
terms of physical abuse, emotional abuse and sexual abuse. They did not
find any difference in term of neglect subtypes (physical and
emotional). According to Nelson (2001) the prevalence of physical and
emotional neglect was similar for addicts and non-addicts but rates of
emotional abuse tended to be higher in addicts.

Furthermore, Young-Wolff, Kendler, Ericson and Prescott conducted a
study on adult twins in Virginia on male alcohol dependents. They
reported that 9 Percent of their participants had experienced neglect,
sexual or physical abuse. The Comparison of two groups ; the group who
had experienced childhood maltreatment, and second group who had not
experienced childhood maltreatment revealed that maltreated group were
1.74 times more likely to be diagnosed with alcohol dependence. Arata,
Langhinrichsen-Rohling, Bowers, and O'Brien have also proposed that
physical, sexual, emotional abuse and neglect contributed to the
development of various psychological disorders.

In addition, Poker (2000; cited in Ramiro et al 2010)12 found that
"Although moderate and predictable stress in childhood can help
develop ways of coping with life in general, severe, repetitive, or
chronic stress hampers normal brain functioning. Neural pathways are
sensitized and regions of the brain (e.g. Hippocampus, sub-cortical and
limbic systems) that deal with anxiety and fear responses become
overdeveloped" (p.852). As a result, the brain is more focused on
dealing with constant threat for survival victim of child abuse show
more high risk behaviours ( e.g., using drugs/substance) to deal with
stressful situations.

The finding indicates that comparative rates of childhood neglect
and abuse in drug addicts and non-drug addicts may be similar in
European or Asian samples.

Limitations

It is important to highlight that results of the study had certain
limitations. First, the instrument used for measuring childhood abuse
and neglect was a self-report retrospective tool. Therefore, chances of
reporting false information might be high. Moreover, due to
non-availability of an indigenous tool, the European tool was used in
English. As Urdu is the first language in Pakistan not English;
therefore, this limitation was minimized by setting the inclusion
criteria for the participants (i.e., minimum 14 years of education). The
reasons behind this are that those who had 14 years of education they
could read and understand English language. However, future studies
should use an indigenous tool so illiterate drug addicts and those who
are less educated could also be include in the data..Second, the sample
size was not large enough and only taken from one city in Pakistan, thus
limiting the generalizability of the results.

Future research should collect the sample from the four provinces
of Pakistan to improve the generalizability of the results.A key
strength of the study is the inclusion of a matched group against which
drug addicts' childhood abuse and neglect was compared. Because,
gender difference was not addressed in this study; future studies should
include females. The present study was conducted to measure childhood
abuse and neglect but other factors that were not addressed (for
instance, inappropriate parenting style, peer pressure, economic
condition, and paternal relationships) may also be important and present
additional directions for future research.

Conclusion

Childhood abuse and neglect are commonly found in the histories of
drug addicts, and it may imply that abuse and neglect increase the risk
for substance abuse and other negative outcomes. It might possible that
drug addicts may use drugs to forget those memories which are related
with neglect and abuse. Psychologists, clinical psychologists,
counsellors, general physicians, and social workers may play a key role
in creating intervention programs to assist children and families to
prevent or address problems of abuse. The Pakistani government should
also implement preventive programs against childhood maltreatment (abuse
and neglect).